Provider Demographics
NPI:1720263973
Name:JENNERJAHN, HANS (PA)
Entity Type:Individual
Prefix:
First Name:HANS
Middle Name:
Last Name:JENNERJAHN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27842
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7842
Mailing Address - Country:US
Mailing Address - Phone:718-670-1651
Mailing Address - Fax:516-437-4167
Practice Address - Street 1:5916 174TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1539
Practice Address - Country:US
Practice Address - Phone:718-670-2731
Practice Address - Fax:516-437-4167
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002482-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0066AWMedicare PIN
NYP00607644Medicare PIN